I authorize my insurance benefits be paid directly to the physician who has treated me.
I understand that I am financially responsible for any balance unpaid by insurance.
I authorize the release of any information to my insurance company required to process my claims.
I understand that it is my responsibility to inform of any insurance coverage and/or eligibility changes and that failing to do so may result in a charge of the full billed amount.
I understand that payment is required at the time of service unless other arrangements have been made and that prompt payment is required with past due accounts being sent to collections. (Returned check fee is $25.00)